1710761788 NPI number — KELCI BLACKWELL BEHAVIOR TECHNICIAN

Table of content: KELCI BLACKWELL BEHAVIOR TECHNICIAN (NPI 1710761788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710761788 NPI number — KELCI BLACKWELL BEHAVIOR TECHNICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKWELL
Provider First Name:
KELCI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BEHAVIOR TECHNICIAN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710761788
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 S DOUGLAS RD STE 230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL GABLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33134-4108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-854-1116
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4301 FORBES BLVD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANHAM
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20706-4446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-854-1116
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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